AN APPROACH TO

PAEDIATRIC
ABDOMINAL PAIN

Dr M Ilyas Saleem
BSc, MBBS, MRCPCH,
MSc (Paediatric Diabetes) FRCPCH
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ABDOMINAL PAIN- A CLINICAL

CONUNDRUM

“After 40 years of extensive experience I still approach the acutely painful abdomen of a child with much
apprehension and a greater feeling of uncertainty than any other domain of childhood”-
Joseph Brennemann, famous Chicago Pediatrician

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WHY IS IT IMPORTANT?
• In observational series describing children with abdominal pain evaluated in outpatient clinics or emergency
departments, 22 percent had diagnoses that required surgery or treatment with antibiotics
• Clinical experience suggests that in most outpatient settings, the proportion of children with serious conditions is
lower.
• Aetiological frequency of diagnoses in one study (ADC 2012)
appendicitis 23%
constipation 20%
gastroenteritis 16.5%
mesenteric adenitis 13%
non-specific abdominal pain (viral syndrome) 10%
urinary tract infections 6%
pneumonia 5%
gastritis 4.4%
asthma 2%
others 0.1%

• Our Goal is to identify those who need urgent intervention & or surgery

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A COMMON PRESENTATION
Setting the scene:

• On Saturday evening Andy’s mother calls the OOH GP service.

• Andy is 8 year old, tummy ache since this morning, has not just settled
• He felt hot in the afternoon and has stayed in his bed since
• He has not eaten anything all day, not tolerating even fluids
The GP suspects an “acute abdomen” and would like to see the child
What is Acute Abdomen?
Acute abdomen or (surgical abdomen) implies an emergency surgical condition as the cause of a
patient’s acute abdominal pain

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 • Acute abdominal pain
lasting more than 4-6
hr
• And getting
CLUES TO ACUTE progressively worse
• Associated anorexia
ABDOMEN
AN ATTACK OF ABDOMINAL PAIN LASTING MORE THAN 3
and nausea
HOURS SHOULD BE REGARDED AS AN ABDOMINAL • Vomiting esp. bilious
EMERGENCY UNTIL PROVEN OTHERWISE- R S
ILLINGWORTH (green)

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HISTORY FROM MUM

• Tummy ache around his belly button soon after getting up in the morning
• Felt sick and picked at his breakfast, mother persuaded him to have some milkshake
• He vomited soon after that, could not keep paracetamol down either
• Mum put it down to “tummy bug” as he had been to the toilet twice for pooh
• Not hungry at lunch time
• In the afternoon, Andy was hot and sweaty and lay down
• Tummy ache has not eased and it is hurting him on the right side of his belly
• GP asks about …..
Recent illnesses, injuries and operation. Mom denies any problems as Andy has been fit and well
until now

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WHY DOES ANDY NOT WANT TO GET UP?

• When there is peritoneal irritation, the pain is “worse on movement” as a result of:
• REBOUND TENDERNESS
• This is noticeable when walking, a jerk to the bed, a jolt in the car seat on the way to the
hospital and coughing
• Pain and tenderness are more intense on PERFORATION and generalised peritonitis-lying still
• Psoas muscle spasm: inflamed appendix abuts onto psoas and it cause hip flexion
• An attempt to get out of bed requires hip extension and would therefore cause abdominal pain

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PITFALLS IN THE DX OF APPENDICITIS

• Presentation may not be “textbook”
• Absence of fever, anorexia,
• Pain in atypical location
• Presence of diarrhoea
• Dysuria and pyuria may confuse the unwary
• Normal blood results DO NOT rule out appendicitis
• Younger child may have non specific symptoms or perforate quickly or develop a mass

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IMPORTANT POINTS IN HX

• PQRSTAAA: (The ECG of Abdominal Pain)

• Position(location): ask child “where is the pain?” poorly localised (visceral), well localised
(somatic)
• Quality: sharp stabbing (trauma), dull diffuse
• Radiation: to the back in pancreatitis, splenic radiates to Left shoulder, gallbladder to Rt shoulder tip
• Severity (intensity): degree on a scale 1-10, pain due to ischaemia and perforation is very severe
• Timing(onset): onset and duration, does it wake the child up at night?
• Alleviating factors: anything that makes it better; either position or movement, medication
• Aggravating factors: anything that makes the pain worse
• Associated symptoms: vomiting (bilious, non bilious), nausea, haematemesis, melaena, fever,
weight loss, diarrhoea or constipation
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• Ask about sexual history (STI),Menstrual cycle (ectopic pregnancy), dysmenorrhoea

• Ask about family history of GI conditions (IBD, IBS),Gallstones,
• Ask about travel history (exotic infections e.g. amoebiasis or Giardiasis
Associated Symptom Relevance
Diarrhea Gastroenteritis, Protein losing enteropathy
Bloody stool UGIB/LGIB, Ulcerative colitis, necrotizing
enterocolitis, dysentery, constipation
Hematemesis UGID, Peptic Ulcer Disease, Gastritis
Bilious emesis Small bowel obstruction
Jaundice Hepatitis or Biliary Tree obstruction
Joint pain/swelling IBD, HSP
Skin Lesions IBD, HSP, Liver disease
Testicular pain Testicular torsion
Dysuria/polyuria/hematuria Urinary tract infection/Pyelonephritis
Vaginal/Penile discharge STI
Dysmenorrhea Endometriosis
Shortness of breath Pneumonia or empyema
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PHYSICAL EXAM AND INVESTIGATIONS

• Gentle and non-threatening approach is essential
• General appearance, posture, pallor, vital parameters, CRT, temperature, foetor oris
ABDOMEN:
Inspection: ( from the end of the bed and side of the bed), abdominal distension, visible peristalsis,
operative scars, skin colour, hernias
Palpation: tenderness, guarding, rebound, rigidity, masses, costovertebral angle
Percussion: tenderness, fluid thrill (ascites)
Auscultation: bowel sounds
Always examine the genitalia in a male presenting with abdominal pain
Rectal examination is unpleasant and only done by the senior clinician/surgeon if indicated
Repeated physical examination is sometimes more revealing than lab tests
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VISCERAL PAIN REFERRAL

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AETIOLOGICAL CLASSIFICATION OF ABDOMINAL PAIN

Abdominal medical surgical

Non-specific abdominal pain appendicitis

Viral gastroenteritis intussusception

Bacterial enterocolitis, Intestinal obstruction

Campylobacter, Salmonella spp

Mesenteric adenitis Peritonitis

Inflammatory Bowel disease Meckel’s diverticulitis

Urinary Tract Pyelonephritis Laceration after blunt injury

Liver and Gallbladder Hepatitis, gallbladder colic,

cholecystitis

Non-abdominal Tonsillitis, lower lobe pneumonia

Others DKA, Sickle cell crisis, HSP

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AGE SPECIFIC DIAGNOSES

Common in Children < 2 years Consider in adolescent (girls) Uncommon in children & adolescents

intussusception Ectopic pregnancy Peptic ulcer

Strangulated inguinal hernia Pelvic inflammatory disease Acute pancreatitis

malrotation Torsion of ovary or cyst Acute cholecystitis, gallbladder stones

Imperforate hymen Renal stones

Torsion testis in boys Herpes zoster

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COMMON DIFFERENTIAL DIAGNOSES
Medical Condition Relevant Findings and Potential Complications

Gastrointestinal

Constipation Infrequent bowel evacuations, difficult or painful defecation, can see blood in stool from anal fissures, low fibre diet, high milk consumption
(>2-3 cups per day)

Acute appendicitis Right lower quadrant pain with fever, anorexia, nausea, vomiting, can rupture and lead to sepsis

Gastroenteritis Vomiting and diarrhea with or without fever and nausea, can have bacterial or viral etiologies

Irritable bowel syndrome Change in stool frequency, bloating, abdominal distension, may be associated with certain foods

Trauma History and signs of bruising

Ulcerative colitis Bloody and/or chronic diarrhea, crampy lower abdominal pain, anorexia, weight loss, fever, fecal urgency, can develop to toxic megacolon

Crohn’s disease Intermittent diarrhea, weight loss, crampy right lower quadrant pain, anorexia, weight loss, fatigue

Celiac Disease Abdominal pain, bloating, growth failure, gluten insensitivity

Inflammatory Bowel Disease Associated with diarrhea, bloody stools, weight loss, can lead to significant growth failure if missed.

Genitourinary

Urinary tract infection Dysuria, polyuria, hematuria, can progress to pyelonephritis

Primary dysmenorrhea History of menstrual periods and regularity, consider sexual history

Pulmonary

Pneumonia and Empyema Consider respiratory history, past medical history and recurrent respiratory tract infections

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Medical Condition Findings on Physical Exam

Gastrointestinal
Constipation Abdominal tenderness, palpable fecal mass, look for imperforate anus or stenosis, spina bifida,
developmental delay, cerebral palsy

Acute appendicitis Patient avoids movement, rebound tenderness, McBurney sign (pain at 2/3 between umbilicus
and right ASIS), Rovsing sign (pain in right lower quadrant on left-sided palpation), Psoas sign
(pain in right lower quadrant when child on left and right hip hyperextended), obturator sign
(pain in right lower quadrant on internal rotation of flexed right thigh)

Gastroenteritis Diffuse pain with no rebound tenderness, abdominal distension, hyperactive bowel sounds

Irritable bowel syndrome Periumbilical tenderness, no rebound tenderness

Trauma Signs of bruising and tenderness

Celiac Disease Growth failure, distended abdomen, diffuse abdominal tenderness.

Inflammatory bowel disease Appears thin/cachetic, abdominal tenderness, anal skin tags, possible sign of bloody stool on
DRE, examine for skin lesions (erythema nodosum, pyoderma gangrenosum), iritis, and joint
inflammation

Genitourinary
Urinary tract infection Fever, suprapubic and costovertebral angle tenderness, irritability, foul-smeling urine, gross
hematuria

Primary dysmenorrhea Lower abdominal tenderness

Pulmonary
Pneumonia and Empyema Tachypnea, cyanosis, decreased breath sounds, crackles and rales, dullness on percussion,
febrile

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LAB INVESTIGATIONS
Medical Condition
Constipation
Acute appendicitis
Gastroenteritis
Irritable bowel syndrome
Trauma
Celiac Disease
Inflammatory Bowel Disease
Urinary tract infection
Primary dysmenorrhea
Pneumonia and Empyema
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Relevant Diagnostic Tests
Gastrointestinal
None if history does not suggest an alternative
diagnosis.
CBC (WBC normal or elevated), urinalysis, urine
pregnancy
Serum electrolytes, stool culture, stool for virology
None, based on history and clinical findings
CBC for blood loss, abdominal CT with contrast
Anti-TTG, IgA
CBC, ESR/CRP, electrolytes, albumin, LFTs,
Bilirubin, Stool culture, AXR
Genitourinary
Urine dipstick (for leukocyte esterase and nitrite),
urine microscopy, urine culture (best if suprapubic
aspirate)
None, based on history and clinical findings
Pulmonary
CBC, Chest x-ray, sputum culture
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UNCOMMON DIAGNOSES & POTENTIAL COMPLICATIONS

Medical Condition Relevant Findings and Potential Complications

Gastrointestinal
Intussusception Colicky pain, flexing of legs, fever, lethargy, vomiting, peak incidence in children at 6 months of age

Mekel’s diverticulum Similar presentation to appendicitis, profuse GI bleeding, can develop to diverticulitis

Mesenteric adenitis Can present like acute appendicitis, recurrent respiratory tract infections

Hirschsprung disease Vomiting, abdominal distension, enterocolitis, primarily in first year of life

Small bowel obstruction Bloating, vomiting, failure to pass flatus or stool, bilious emesis

Volvulus Can present like small bowel obstruction, due to intestinal twisting

Large bowel obstruction Abdominal distension, hard feces and rectal bleeding, can lead to bowel perforation

Necrotizing enterocolitis Feeding intolerance, apnea, lethargy, bloody stools, abdominal distension and tenderness, abdominal
erythema, hematochezia, bradycardiac, primarily in premature infants

Peptic ulcer disease Epigastric tenderness, pain related to eating a meal, ulcer can perforate

Viral hepatitis Fever, malaise and jaundice, consider fecal-oral or vertical transmission

Acute pancreatitis Steady and sudden-onset pain radiating to the back, nausea, vomiting, history of cholelithiasis

Splenic infarction Personal or family history of sickle cell disease

Genitourinary
Nephrolithiasis Acute renal colic, flank pain radiating to groin

Testicular torsion Testicular pain with acute onset, nausea, vomiting

Ovarian torsion Pain with nausea, vomiting, diarrhea

Ruptured ovarian cyst Bloating, early satiety
Pelvic inflammatory disease Consider sexual history

Pregnancy and related complications Nausea and vomiting, review sexual history and consider ectopic pregnancy and associated ruptures

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FINDINGS ON PHYSICAL EXAMINATION OF UNCOMMON CONDITIONS

Medical Condition Findings on Physical Exam
Gastrointestinal
Intussusception Gross or occult blood, abdominal tenderness and palpable abdominal mass

Merkel diverticulum Bloody stools, abdominal tenderness with guarding, rebound tenderness

Mesenteric adenitis Diffuse abdominal tenderness, rhinorrhea and pharyngitis, extramesenteric lymphadenopathy

Hirschsprung disease Abdominal distension, palpable fecal mass, small rectum

Small bowel obstruction Hyperactive or hypoactive bowel sounds

Volvulus Diffuse abdominal distension, no bowel sounds, guarding, rebound tenderness, rigid abdomen, fever, hematochezia

Large bowel obstruction distended abdomen, hyperactive bowel sounds

Necrotizing enterocolitis Abdominal distension, tenderness, abdominal wall erythema, hematochezia, bradycardia

Peptic ulcer disease Epigastric tenderness, melena or occult blood

Viral hepatitis Jaundice, hepatosplenomegaly, lymphadenopathy, wasting, cachexia, ascites, asterixis, caput medusa

Acute pancreatitis Epigastric tenderness, tachycardia, irritability, abdominal distension, Cullen sign (discoloration around umbilicus), Grey-Turner sign
(discoloration around flanks)

Splenic infarction Left upper quadrant tenderness

Genitourinary
Nephrolithiasis Costovertebral angle and flank tenderness, tachycardia

Testicular torsion Tender, edematous testicle, affected testicle higher than unaffected, absent cremasteric reflex

Ovarian torsion Tender pelvic mass, cervical motion tenderness

Ruptured ovarian cyst Adnexal tenderness

Pelvic inflammatory disease Slight fever, cervical motion tenderness, adnexal tenderness, vaginal or cervical mucopurulent discharge

Pregnancy and related complications Abdominal tenderness, vaginal bleeding

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COVID-19 ERA
PIMS-TS

• A new syndrome presenting with abdominal pain, vomiting, and /or chest pain
• PIMS-TS has been misdiagnosed as acute appendicitis/surgical abdomen
• Ask about recent COVID positive illness

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NECROTISING TIP OF APPENDIX

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MECKEL’S DIVERTICULUM (RULE OF 2)

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INTUSSUSCEPTION

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HIRSCHSPRUNG’S DISEASE IN A NEONATE

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DUODENAL ATRESIA (DOUBLE BUBBLE-DOWN SYNDROME)

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INCARCERATED HERNIA (RT)

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GALLSTONES

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TESTICULAR TORSION (TORSION OF HYDATID MORGAGNI-TESTICULAR APPENDIX)

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TESTICULAR TORSION IN A NEONATE

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INTRA-OPERATIVE FINDINGS- NECROTIC APPENDIX OF THE TESTIS

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TORSION OF AN OVARY

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AN EASY ALGORITHM FOR THE DUMMIES